Phase One Evaluation of the Mental Wellness Program

Program Relevance

The MWP remained highly relevant and there was a great need for ongoing and adequate funding. Supports and services funded through the MWP are needed to address the enduring legacy of settler colonialism and to support good health and well-being for First Nations and Inuit across the lifespan. Many factors drove increased demand on the programs/services funded through the MWP, including continued growth in demand, the COVID-19 pandemic, re-activation of trauma, ^{Footnote 3} the toxic drug supply and continuing overdose crisis. As well, the evaluation timeframe was marked by greater discussion of mental wellness and awareness of the experiences of survivors (including, Survivors of Indian Residential Schools, Federal Indian Day Schools, the Sixties Scoop, and Missing and Murdered Indigenous women, girls, and Two-Spirit people). Almost all key informants (FNIHB, Inuit, First Nations) agreed that the funding through the MWP was relevant to the priorities of First Nations and Inuit, owing to its improved flexibility (particularly through the Mental Wellness Alignment), recent funding enhancements, and investments in key issues identified by partners. A few indicated that funding could be more aligned through attention to capital needs and priority populations (shown below).

Effectiveness

Design, Delivery, and Efficiency

A key change to the MWP was the introduction of the Mental Wellness Alignment in 2020, which enabled greater flexibility for those in Set and Fixed Agreements to plan and deliver programs holistically with streamlined reporting accountabilities. Some felt that the support offered through the MWP could be improved through addressing internal management concerns (e.g., turnover, misplaced funding reports within FNIHB), strengthening communication (e.g., related to the Alignment), focusing on consistency in reporting requirements, and improving intra-departmental collaboration. Indeed, while the departmental transfer of FNIHB from Health Canada to ISC fostered alignment and a common vision, key informants felt that opportunities to collectively advance key issues (e.g., the social determinants of health, children and youth) had not been maximized.

Despite program enhancements (e.g., 56% increase in contributions spending), there was strong agreement that the available financial resources within the program did not meet the demand for services. The following constraints were identified as it related to program funding:

• Increased need/demand: Key informants felt that funding had not kept pace with factors including population growth, inflation, competitive wages, and increased program demand.
• Sustainability: According to MWP staff, about half of total program funding was time limited. As well, though the program received additional funding during the evaluation timeframe, an estimated $437.9M per year was time limited funding that would need to be renewed.  Lack of sustainable funding creates challenges for communities and service delivery organizations. Examples of where these challenges lie include recruiting and retaining staff, forward planning, program development, and mental wellness promotion
• Growth: Less than half of MWP funding included a 3% annual escalator at the start of the evaluation timeframe (2016), and funding received in later years did not have escalators attached to it, making it difficult for communities to keep pace with rising costs.

Alongside improving funding approaches, ^{Footnote 4} key informants recommended enhancing support for the mental wellness workforce in collaboration with national partner organizations such as through a dedicated workforce strategy, mentorship and laddered training, and focusing on knowledge sharing.

Children and Youth

Despite several funding streams having the flexibility to support First Nations and Inuit children, youth and families, greater supports for these groups, including through enhanced mental wellness prevention and early identification was a common priority identified within First Nations and Inuit contexts. Examples of how this could be supported included more resiliency-based programming, in-school counselling supports, land-based activities, and treatment centre services.

Some felt that there had been limited targeted funding within the MWP for children and youth and that there was a lack of coordination across the department, leading to youth "falling through the cracks." Regionally, First Nations and Inuit also explained that meeting the needs of children, youth, and families can be impeded by a lack of available facilities/infrastructure, limited funding to invest in population-specific programs, and limited capacity of staff to plan and deliver programs. These challenges can be amplified for remote and isolated communities, in particular.

Climate Change

Notwithstanding the considerable diversity in worldviews, knowledges, perspectives, and contexts of First Nations and Inuit, climate change has disrupted many of the determinants of well-being for Indigenous peoples, including engaging in land and culture-based activities, access to traditional medicines, sharing knowledge across generations, and food security. Furthermore, evacuation events have led to increased stress, grief, and relocation to environments that are not conducive to the well-being of community members and those attached to services.

Regionally, MWP representatives, MWTs, and Health and Cultural Support Workers have supported emergency efforts through crisis response efforts, service coordination, and setting up pop-up services. Recognizing the increasing threat of climate change events and the close connection with mental wellness, a continuing increase in demand for services may be expected. Representatives agreed that collaboration efforts should increase alongside communities/organizations and with Health Emergency Management.

Service Transfer

The MWP undertook efforts to support self-determination and First Nation and Inuit control over mental wellness services. This included offering more flexibility in funding agreements by consolidating funding envelopes, streamlining reporting, supporting Indigenous partner-led workforce development, and focusing on de-centralized decision making through regionally-based partnership structures.

The stated primary barrier affecting the journey towards service transfer was the need for additional and sustainable funding to enable communities to deliver a suite of holistic programming, retain qualified staff, stabilize and restore capacity, access training, and engage in long-term planning. Further to this, funding stipulations and specific reporting requirements committed to central agencies were seen as inconsistent with the department's mandate, alongside a lack of internal collaboration/integration. While there is no one "best practice" to fostering service transfer, key informants and supporting literature reported promising practices that can facilitate this vision, including ensuring appropriate funding (e.g., adequate, sustainable, flexible, long-term, simplified), restoring capacity and supporting workforce development, and supportive partnerships (e.g., between federal government/departments, First Nations and Inuit, and provincial and territorial representatives).

The COVID-19 Pandemic

Numerous challenges were introduced or enhanced by the pandemic, including worsening of mental health and exacerbation of inequities in the social determinants of health, service limitations, rising acuity of needs, and population-specific impacts. Communities were supported to adapt and expand mental wellness services through a temporary influx of flexible funding among other measures. Commonly, communities and organizations introduced or enhanced land-based programming, adapted existing programs to address public health measures, and/or introduced virtual programming.

The broad funding authorities and influx of flexible funding were seen as strengths to mitigating the impacts of the COVID-19 pandemic. However, the time-limited nature of funding necessarily meant that communities could not continue with programs despite demands and evidence of success and need.

Overview

This Management Response and Action Plan was developed to address recommendations presented in the Evaluation of the Mental Wellness Program. The MRAP was developed by Indigenous Services Canada's First Nations and Inuit Health Branch (ISC-FNIHB) in collaboration with the Evaluation Directorate.

ISC-FNIHB acknowledges and concurs with the recommendations outlined in the report of the phase one evaluation of the Mental Wellness Program conducted by ISC's Evaluation Directorate.

ISC-FNIHB is committed to supporting Indigenous Peoples on their journey towards self-determination and transferring control of services to Indigenous partners. ISC-FNIHB recognizes that mental wellness is a key priority for First Nations, Inuit, and Métis, and will continue to work with partners and communities to advance their mental wellness priorities.

The evaluation period coincided with a period of considerable change, both internal and external.  FNIHB transferred from Health Canada to the newly formed Indigenous Services Canada; the mental wellness program consolidated a number of "sub-sub-programs" under a single umbrella "sub-program" in order to increase flexibility in program delivery and reporting; and the Covid-19 pandemic impacted mental wellness needs and the ways services were delivered. 

ISC-FNIHB is committed to taking action on all of the recommendations and has already begun much of this work. It is also looking forward to hearing directly from Indigenous partners through the "phase two" studies, and to use the recommendations that emerge from that work to make further improvements. 

In the time since the evaluation period, ISC-FNIHB has worked with partners to make changes which address many of the recommendations proposed in this report. Funding for the mental wellness program has more than doubled since the beginning of the evaluation period, with investments for new, enhanced, or renewed services in Budgets 2016, 2017, 2018, 2019, 2021, 2022, and 2024.  In 2022, ISC-FNIHB hosted the first national mental wellness summit, which showcased Indigenous-led approaches to mental wellness and supported knowledge sharing and collaboration. We prioritized workforce development including providing funding for Indigenous partners to develop a workforce strategy and to explore the development of a mental wellness workforce association. We supported Indigenous-led approaches to evaluation including by funding two excellent pieces of work undertaken by the First People's Wellness Circle which used culturally relevant and appropriate methodologies to assess the impact of the Indian Residential Schools Resolution Health Support Program. Finally, we have been working at modernizing our approach to results through the development of a results framework that is organized around 4 pillars:  availability, accessibility, quality, and effectiveness.

While we concur with all the recommendations, it is important to note that some elements of recommendation 3 fall outside of the direct control of the Mental Wellness Program.  In particular, the Mental Wellness Program does not have ultimate control over annual program budget levels, funding profiles, or funding escalators.  The response to this recommendation reflects actions that are within the purview of the program.

An annual review of the Management Response and Action Plan will be conducted by ISC Evaluation Directorate and shared with the ISC Performance Management and Evaluation Committee to monitor progress and activities.

Assurance

The Action Plan presents appropriate and realistic measures to address the evaluation's recommendations, as well as timelines for initiating and completing the actions.

Recommendation 1

ISC should support an Indigenous-led second phase of study that focuses on First Nations and Inuit community voices that were not captured within Phase One.

Action 1.1: Indigenous Services Canada will support an Indigenous-led second phase of study by providing funding for Indigenous-led and community-focused evaluations of treatment centres, mental wellness teams, and opioid agonist treatment wraparound services. (March 31, 2026, to be confirmed with the partners undertaking the work)

Recommendation 2

ISC should review and identify measures to advance a) intra-departmental; and b) regional partner collaboration to better address the complex and multi-faceted challenges present within mental wellness (e.g., the social determinants of health, Health Emergency Management planning, children and youth).

Indigenous Services Canada will continue to collaborate with regions and sectors to address mental wellness needs in the context of the social determinants of health and other interrelated factors.

Action 2.1 (a): Establish tracking system for Statements of Local Emergency, facilitating equal access to information, and improving opportunities for collaboration between the mental wellness program and other programs/ sectors which support emergency response (Completed, 2021).

Action 2.2 (b): Host National Summits on Indigenous Mental Wellness (Completed, 2024).

Action 2.3 (b): Support ongoing regional collaboration and knowledge sharing with mental wellness leads from each FNIHB region, including sharing updates from regional partnership tables. Monthly virtual meetings, annual bilateral meetings, and an annual in-person meeting. (ongoing)

Recommendation 3

ISC should develop options for overcoming the program delivery challenges created by restrictions on capital spending and revisit and update as required the program's funding approaches, including with respect to the need for sufficient ongoing funding with appropriate escalators, and the appropriate distribution of available funds.

Indigenous Services Canada will update and refine the funding formulas used to allocate mental wellness resources on an ongoing basis, based on the most relevant and recent data, and will fund knowledge development to inform costing and funding allocations for the mental wellness program.

Action 3.1: Update population-based regional funding allocations with the latest available population data. (Completed, 2024)

Action 3.2: Work with Health Facilities and Infrastructure to map out infrastructure needs and identify options to support community capital needs related to mental wellness. (March 31, 2026)

Action 3.3: Commission a report(s) to assess the funding required to continue to deliver existing mental wellness services and/or to expand or improve mental wellness services with considerations including such issues as capital and infrastructure needs, escalators, distribution of funds, and competitive wages. (March 31, 2026)

Recommendation 4

ISC should work collaboratively with First Nations and Inuit partners to explore opportunities/mechanisms that could further support workforce development and support an updated assessment of the impacts of competitive wages on workforce development and retention.

Indigenous Services Canada will continue to work with key Indigenous partners to support community-based workforce development, including through providing funding to Indigenous organizations to develop initiatives to support, enhance, and develop the community-based workforce.

Action 4.1: Provide funding for national Indigenous organizations (e.g. Inuit Tapiriit Kanatami, National Centre for Truth and Reconciliation) and Indigenous subject matter experts (e.g. 2 Spirits in Motion, We Matter) to develop resources and training materials for the community-based mental wellness workforce. (Completed, 2024)

Action 4.2: Provide funding for the development of the First Peoples Wellness Circle's Formative Analysis for the IRS Resolution Health Support Program, which includes recommendations around training needs and networking opportunities for the trauma-specialized workforce. (Completed, 2024)

Action 4.3: Support the First Peoples Wellness Circle and Thunderbird Partnership Foundation to develop a workforce wellness strategy. (Completed, 2024)

Action 4.4: Provide funding to support the Thunderbird Partnership Foundation and First Peoples Wellness Circle to explore the development of a national mental wellness workforce association that could consider various priority issues including how to continue to assess the impacts of competitive wages on workforce development and retention. (March 31, 2026)

Recommendation 5

ISC should work collaboratively with partners to identify opportunities to align performance measurement activities with community perspectives on wellness, ensure alignment between the logic model and program indictors, and continue to fund partner-led assessments to gather meaningful data (e.g., on important topics, issues, and population-specific considerations within the MWP)

Indigenous Services Canada will continue to work collaboratively with Indigenous partners to develop culturally appropriate and relevant approaches to performance measurement, supporting and leveraging the work of Indigenous partners, and implementing the Mental Wellness Program Results Framework.

Action 5.1: The Mental Wellness Program will provide funding to Indigenous organizations to build capacity and/or implement culturally appropriate and relevant approaches to performance measurement and/or evaluation. (March 31, 2025)

Action 5.2: The Mental Wellness Program will provide a Program Results Framework to the Treasury Board Secretariat, outlining the Mental Wellness Program's proposed approach to performance measurement, key considerations involved in this work, and the preliminary structure of the Results Framework. (Winter/Spring 2024/2025)

Action 5.3: The Mental Wellness Program will implement the Program Results Framework, including the logic model and corresponding performance indicators considerations, developed under the four key themes of Availability, Accessibility, Quality, and Effectiveness. (March 31, 2026)

Health and Cultural Supports

Indian Residential Schools Resolution Health Support Program: This program was initially established as part of the 2006 Indian Residential Schools Settlement Agreement, and provides access to mental health counselling, emotional, and cultural support services to former students of Indian Residential Schools and their families. Services include access to cultural and emotional supports; professional counselling services (individual and family); and assistance with the cost of transportation services (to access counselling services and/or cultural supports).

• Cultural and emotional support workers are hired by community organizations to provide services. Cultural support services are provided by Elders or traditional healers and emotional support services are provided by trained and trauma-informed Indigenous health workers. ISC holds over 135 contribution agreements with organizations across the country to provide these supports.
• Mental health counselling services are provided by regulated service providers such as psychologists and social workers, registered in their province or territory, and enrolled with ISC. Funding for professional mental health counselling services is primarily provided on a ‘fee for service' basis (service providers invoice ISC). In cases where professional mental health counselling is not available locally, ISC provides support for medical transportation, based on Non-Insured Benefits Program policies and guidelines.

Missing and Murdered Indigenous Women and Girls: In June 2018, in response to the Interim Report of the National Inquiry on Missing and Murdered Indigenous Women and Girls, the Government announced funding for health and cultural supports for survivors, family members, and others affected by this issue.  These services mirror those offered through the Indian Residential Schools Resolution Health Support Program but are part of the Brighter Futures funding envelope.

Indian Day Schools: In June 2020, the Government announced funding for health supports for former students of historic Federal Indian Day Schools and their family members. Indian Day Schools health and cultural support services mirror those available through the Indian Residential Schools Resolution Health Support Program but are part of the Brighter Futures funding envelope.

Community-based Mental Wellness

Funding is allocated to communities based on priorities and needs established through regional partnership structure and decision-making processes. Outlined below is a description of funding that flows to communities or to organizations providing mental wellness services to communities. This description does not include substance-use related and suicide prevention/life promotion funding, both of which are covered in separate sections. Much of this funding falls under the Mental Wellness Alignment.

Brighter Futures: Brighter Futures was launched in 1992 with the purpose of improving the quality of and access to culturally appropriate, holistic and community-directed mental health, child development, solvent abuse and injury prevention services at the community level. The aim is to help create healthy family and community environments in which community members and children can thrive. First Nations and Inuit communities and territorial governments are eligible to receive funding for this program. Allocation of funding is guided by regional partnership tables and structures.

Building Healthy Communities: Launched in 1994, the Building Healthy Communities program was designed to assist First Nations and Inuit communities and territorial governments in developing community-based approaches to mental health crisis management. Mental health and crisis intervention activities include assessments; counselling services; referrals for treatment and follow-up treatment; and aftercare and rehabilitation to individuals and communities in crisis.  Examples of other activities supported by the program include peer support groups; culturally appropriate accredited training on crisis management and intervention; trauma and suicide prevention training for community members and caregivers; and, education and awareness activities that lead to improved mental wellness and suicide prevention. The program also supports community capacity building by training caregivers and community members to deliver mental health-related programs and services. Allocation of funding is guided by regional partnership table and structures.

Victims of Violence: In 2014, the Health Minister committed to $10M annually over ten years to support family violence prevention. The Public Health Agency of Canada (PHAC) administers $7M to address family violence issues across Canada. FNIHB administers $3M to address First Nations (on-reserve) and Inuit family violence issues through the Non-Insured Health Benefits Program and the MWP. Funding through the MWP largely flows to regions, with approximately $161K to the First Nations Health Authority in British Columbia in the first year and then dividing this amount among National Indigenous Organizations that address family violence in subsequent years (e.g., Native Women's Association of Canada, Pauktuutit).

Mental Wellness Teams: Mental Wellness Teams (MWT) are community-based, client-centred, multi-disciplinary teams that provide a variety of culturally-safe mental wellness services and supports to First Nations and Inuit communities using a wide diversity of service models which may include crisis response, capacity-building, trauma-informed care, land-based care, prevention, early intervention and screening, after care, and care coordination with provincial and territorial services. All MWTs are defined and driven by the community and can include Indigenous traditional, cultural and mainstream clinical approaches to mental wellness services, spanning the continuum of care from prevention to after-care. Each mental wellness team serves a community or cluster of communities and can include a variety of community-based and clinical professionals. The combination of services provided, and composition of the team reflects community needs and priorities. The MWTs are delivered either by First Nations and Inuit communities, tribal councils or organizations with funding provided by contribution agreements with FNIHB. There are currently 71 Teams serving 359 First Nations and Inuit communities.

Suicide Prevention/Life Promotion

National Aboriginal Youth Suicide Prevention Strategy (NAYSPS): Launched in 2005, NAYSPS supports community-based activities to improve mental wellness among Indigenous youth, families, and communities by strengthening protective factors and decreasing risk factors for suicide. The target populations are First Nations youth living on-reserve and Inuit youth living in recognized Inuit communities, ages 10 to 30 years. Eligible recipients include: First Nations and Inuit community health authorities or Band Councils, Tribal Councils, provincial or territorial governments, First Nation or Inuit Land Claimant Organizations, other First Nations or Inuit organizations, and other non-profit organizations supporting First Nations and Inuit communities. This funding is guided by the following principles in that projects should: be evidence-based; use community-based approaches; be community-driven; be culturally-relevant, -appropriate, and -safe; incorporate elements of primary, secondary, and tertiary prevention; meaningfully involve youth; consider varying levels of community readiness; respect local cultures and traditions; promote the prevention of suicide as everyone's responsibility; complement provincial and territorial mandates, and; promote life and well-being. How funding is allocated to recipients differs across regions and is supported by direction from partnership tables and decision-making structures.

Youth Hope Fund (YHF): The YHF is a national level initiative that supports distinctions-based, Indigenous youth-led projects on life promotion. Supported by Budget 2017, this initiative is guided by Indigenous youth and invested $12M over five years with $3.4M per year on-going. First Nations youth and Inuit youth guide approaches to funding through separate decision-making processes. Eligibility, terms and conditions align with those of NAYSPS.

National Inuit Suicide Prevention Strategy (NISPS): NISPS was developed by the ITK and partners to address the high rates of suicide for Inuit living in Inuit Nunangat. Launched in 2016, it was funded via interim measures in 2016 at $9M over three years in response to the need for new funding to support Inuit mental wellness. Budget 2019 committed $50M over 10 years with $5M per year on-going. Funding is allocated directly to ITK and regional Land Claim Organizations.

Substance Use Prevention and Treatment

Specific to problematic substance use, prevention and treatment, ISC currently funds a network of 45 treatment centres (31 adult, 9 youth and 5 family), as well as drug and alcohol prevention services in the majority of Indigenous communities across Canada.

Treatment Centres: Treatment centres provide a range of mainstream and culturally relevant approaches; access to inpatient, outpatient, and day treatment services; services for unique needs (e.g., programming for families, solvent or problematic drug use, and concurrent disorders); and are grounded in traditional culture. These centres are operated by First Nations and Inuit organizations and/or communities.

Community-based: The community-based component provides prevention, intervention, aftercare and follow-up services in First Nations and Inuit communities across Canada. In most communities, this component is delivered by community-based workers who are responsible for identifying community needs and delivering program activities. This can include cultural activities including on-the-land, education and awareness activities, youth-specific activities, providing training and education to front line workers, providing appropriate assessment of clients and referral of clients to other services including substance use treatment, and providing community level aftercare services to clients returning from residential treatment.

Other funded components include:

Opioids-specific programming: To respond to public health challenges presented by the ongoing opioid crisis, funding has also been provided to support opioid agonist therapy sites that offer comprehensive wraparound services in areas of high need. Wraparound sites support access to community-based psychosocial services and supports for the treatment of addictions (e.g., wrap-around care). Psychosocial services are community-specific, and can include conventional interdisciplinary treatment (e.g., group, individual, and/or family therapy with trained mental health workers and counsellors/tele-counselling, life skills development, ‘aftercare', etc.), and community-based services and supports grounded in culture (such as land-based healing, ‘wraparound' care, healing centers, elder referral, resiliency building interventions, etc.).  Minimal, moderate, or comprehensive psychosocial services and supports for the treatment of substance use are offered either on-reserve or within 1 hour of ground/water travel. The program has also undertaken the coordination of bulk purchases of naloxone and nasal spray naloxone and increasing access to take-home naloxone kits and training in their use.

Quality Improvement: Through ongoing funding secured under the Canadian Drugs and Substances Strategy (CDSS), ISC-FNIHB supports a number of quality improvement activities.

• Certification: The issue of attracting and retaining skilled workers in the substance use field is recognized as an ongoing challenge for treatment centres and communities. ISC-FNIHB provides communities and treatment centres with additional funding to attract and retain these workers through financial incentives and enhanced training opportunities, both tied to the certification of substance use treatment counsellors and community-based workers.
• Accreditation: ISC-FNIHB also provides funding to support treatment centres to attain and retain accreditation. Accreditation is a process that treatment centres use to assess and to improve the quality of their services.  This includes examining everyday activities and services against national standards of excellence.  Accreditation provides valuable measures to use within and among organizations to reinforce organizational strengths and build important linkages within community and between community and other health services.  Centres have implemented many best practices within their programs as a result of accreditation.  Through ISC-FNIHB funding support, 85% of centres (2017-18 reporting) are accredited or are in the process of becoming accredited.
• Modernization: Funding is provided to treatment centres to support modernization and reorientation of services to strengthen and expand services to better meet client needs.

Alongside delivering funding for the provision of services, core activities of the MWP include:

• Collaborating with Partners
• Developing Program Policy
• Sharing Knowledge
• Building Capacity
• Supporting Self-Determination

Mental Wellness Program Alignment

Changes have been made to the MWP to respond to an identified need for a more holistic approach to mental wellness (e.g., as concluded from the 2016 Evaluation of the First Nations and Inuit Mental Wellness Programs and regional needs assessments) and to align with the priorities articulated in key partner frameworks. Prior to the 2020 Mental Wellness Alignment, recipients received separate funding for each funding stream they administered, implemented in-line with the required objectives and activities of their corresponding FNIHB-MWP program plans, and submitted separate reporting (e.g., through the Community-Based Reporting Template).

Through the Alignment, several community-based programs were aligned (i.e., collapsed) into a single pot of funding. This was intended to reduce siloes and support greater flexibility for recipients to plan programs according to unique community needs, regardless of their type of funding agreement.^{Footnote 11} A revised Mental Wellness Program Plan and reporting guide was also subsequently developed to replace the existing plans of the previously independent funding streams (i.e., presenting one overarching program plan in-line with the continuum framework). As Mental Wellness Alignment occurred near the end of the evaluation timeframe, preliminary/early perceptions of its impacts were explored with key informants familiar with the Alignment; however, more engagement with communities through Phase 2 and beyond will provide more information on the impact of alignment. The figure below presents the funding streams that were collapsed through the Mental Wellness Alignment as well as funding streams that continued to be administered separately (i.e., not all programs within the MWP were aligned).

Text alternative for MWP Alignment

Figure 1 displays the Mental Wellness Program's alignment. The sub-programs that were previously funded and reported on separately:

• Brighter Futures
• Building Healthy Communities
• National Aboriginal Youth Suicide Prevention Strategy
• Community based National Native Alcohol and Drug Abuse Program
• Mental Wellness Teams
• Canadian Drugs and Substances Strategy

These were combined to become the 2020 Mental Wellness Program Alignment. Contribution agreement holders receive one pot of funding and one Program Plan intended to support a more wholistic community-based approach.

The programs that were not included in the aligned Mental Wellness Program and continued to be administered separately with unique reporting requirements^{Footnote 12}:

• Indian Residential Schools Resolution Health Support Program
• Federally funded addictions treatment centres

Accordingly, recipient reporting for funding related to those sub-programs included in Mental Wellness Alignment, was streamlined with the introduction of a new overarching "Mental Wellness Program" data collection instrument, although separate instruments continued to be used for programs that remain separate (e.g., Indian Residential Schools (IRS) Resolution Health Support Program and federally funded Substance Use Treatment Centres).

Program Resources

Funding for the Mental Wellness Program increased during the evaluation timeframe from an approximate annual allocation of $236M in 2015-2016 to $481M in 2021-22.^{Footnote 13}  The table below presents MW Program expenditures by functional area. In 2020-2021, several functional areas were collapsed under the Mental Wellness Program Alignment, as indicated by grey-shaded boxes.

Most of this increase was owing to new investments, though some mental wellness funding streams do include a 3% escalator that contributed to growth. Regarding the longevity of funding, an estimated $437.9M per year (48% of total new investments announced) was time limited.^{Footnote 14} These additional investments were received to meet the immediate mental wellness needs of communities by supporting Indigenous-led suicide prevention, life promotion, and crisis response, including through crisis line intervention services, and enhancing the delivery of culturally appropriate substance use treatment and prevention services in Indigenous communities. They also included funding for mental health, cultural, and emotional support to Survivors and Intergenerational Survivors of Indian Residential Schools and Federal Indian Day Schools  as well as those affected by the tragedy of Missing and Murdered Indigenous Women and Girls.

Resource Allocation

Generally, Mental Wellness funding is not proposal based, but is allocated and provided to communities, treatment centres, and regional and national Indigenous organizations in several ways. Over the years, new funding was allocated from FNIHB headquarters to regions based on the Modified Berger Formula, needs-based allocations, and/or through distributing base funding for all regions. Where the funding was ongoing, it remained fixed at those established levels. Regions subsequently distribute their allocations to recipients, where decisions related to community-based funding often occur through regional partnership structures.

Program Management

The MWP is coordinated and supported by FNIHB staff within both the national and regional offices. FNIHB-MWP staff at the National Office lead strategic policy development and planning in support of the MWP, collaborating with FNIHB regional offices and First Nations and Inuit partners. The core responsibilities of National Office include but are not limited to:

• Strategic policy, including budget proposals and Treasury Board submissions
• Funding allocations for new investments
• National program monitoring, data collection and analysis, supporting audit and evaluation
• Working with regional FNIHB MWP staff to support program delivery, cross-regional sharing, and policy development
• Collaboration with national First Nations and Inuit organizations.
• Supporting linkages with Other Government Departments as relevant
• Coordinating national initiatives, funding and contribution agreements (e.g., Youth Hope Fund)

Regional offices are located within the Atlantic, Northern, Quebec, Ontario, Manitoba, Saskatchewan, and Alberta Regions. In British Columbia, as part of the British Columbia Tripartite Framework Agreement on First Nation Health Governance, the Government of Canada transferred its role in the design, management, and delivery of First Nations health programming to the First Nations Health Authority.

The FNIHB regional offices play a lead role in supporting communities and service delivery organizations with program delivery by working with First Nations and Inuit partnership tables and structures. The regional offices are also responsible for the management of funding arrangements, program performance monitoring, and information roll-ups. Given the diversity of contexts, regions have diverse operations and models in-line with unique priorities and realities. They also have unique regional partnership structures that support decisions around investments and programming.

Program Partners

FNIHB works with key partners at the national and regional levels to inform program and policy development and support service delivery. National Indigenous partners help to shape, guide, and advance the First Nations and Inuit health policy agendas as well as develop tools and resources to guide communities and service delivery organizations, and regional partners play a critical role in service design and delivery. Additional details about key FNIHB partnerships include:

• National Indigenous Partners: Key national partners include the Assembly of First Nations (AFN) and Inuit Tapiriit Kanatami (ITK), both of whom are members on FNIHB's Senior Management Committee on Policy and Planning, as well as the Thunderbird Partnership Foundation, First Peoples Wellness Circle, and We Matter. Other partner organizations support the delivery of national level initiatives as relevant. Collaboration with partner organizations is key to identifying priorities, gaps, challenges, and opportunities that are essential to policy and programming.
• Regional Partnerships: Funding is allocated to communities and/or service delivery organizations based on priorities and needs guided by regional partnership structures, including in some cases, formal regional partnership tables and decision-making processes. Differing models exist across regions, with some regions having formal decision-making tables and processes directed by Indigenous partners to identify priorities and emerging issues. As examples, the Alberta region involves the Alberta Health Co-Management Table; the Northern region involves several bi/tri-lateral partnership mechanisms; the Quebec region includes the Permanent Partners Committee; and the Atlantic region includes the Atlantic First Nations Health Partnership Table and the Labrador Inuit Tripartite Health Committee.

Phased Evaluation Approach

Given the importance of both the program and the subject of mental wellness for Indigenous communities, the EAG highlighted the need for an Indigenous-guided approach to the evaluation that focused on community voices; however, it was recognized that such an approach would be a challenge given that limited time remained to complete the evaluation within the five-year window prescribed by the Financial Administration Act.

As such, the EAG proposed that a phased approach would focus on different aspects of the MWP, meet required timelines, and allow for time to meaningfully engage with First Nations and Inuit partners and communities. Therefore, the content within this report reflects findings from the initial phase and does not include all relevant evidence, including information from community-based leadership, staff and clients of the MWP. The first recommendation of this report, however, is to support an Indigenous partner-led second phase of study that focuses on evidence from First Nations and Inuit communities that was not captured within Phase One. Discussions are already underway to advance planning and design for the second phase of the study. 

Based on guidance from the EAG, the initial phase of the evaluation focused on the governance-level, with representation limited to national and regional-level perspectives (e.g., national partner organizations, regional representatives overseeing funding, coordination, and/or management of services, and a small number of treatment centre representatives) as well as the perspectives of MWP staff. The evaluation questions used to guide the initial phase of the evaluation are provided in Appendix C.

Literature Review

The evaluation team reviewed existing literature to assess select issues/questions of interest, including key needs, priorities, and gaps as they relate to Inuit and First Nations mental wellness; health governance and service transformation; the COVID-19 pandemic; and perspectives on climate change. The review included both peer-reviewed (scientific and academic) and grey literature (relevant media articles and websites) from a variety of sources (e.g., National Collaborating Centre for Indigenous Health, relevant publications, resources from Indigenous and community-based groups).

Document and Data Review

Program documents and data were reviewed to support understanding of program context (e.g., foundational documents, frameworks, key changes), governance, key activities, as well as what has been accomplished to date with respect to objectives and goals. The document review also leveraged resources developed by First Nations and Inuit organizational partners, such as sub-program evaluations, needs assessments, advocacy documents, and other research reports. Furthermore, the evaluation reviewed data collected and held by ISC, including financial data (i.e., total budget allocation and expenditure) and performance measurement data.  

Key Informant Interviews

Interviews were conducted with representatives of national and regional First Nations and Inuit organizations, as well as with FNIHB staff at the national and regional levels. FNIHB-MWP staff were identified by National Office staff; First Nations and Inuit representatives were identified by the EAG and through a snowball sampling approach (e.g., suggestions provided by regional FNIHB staff who were interviewed). Efforts were made to ensure regional representatives (i.e., all regions with the exception of British Columbia) and to engage Inuit and First Nations partners representing a diversity of contexts (e.g., urban, remote and isolated). The objective of the interviews was to gather in-depth information from a variety of perspectives on various issues related to the MWP. The interviews were semi-structured to provide participants with greater opportunity to share lessons, experiences, views, and observations that they believed to be relevant to the MWP and the broader topic of mental wellness. The table below provides a breakdown of respondents by sub-group.

Limitations and Mitigation Strategies

Limitation 1. Retrospective focus of the evaluation. Evaluation contributors were asked to provide retrospective feedback on the MWP (2015-16 to 2020-21). There is a risk that contributors inadvertently spoke to the present-day context and/or were only familiar with more recent program context due to staff changeover.

Mitigation 1. To mitigate this risk, all prospective interviewees were advised of the timeframe prior to agreeing to an interview. At the time of the interview, participants were again reminded of the timeframe.

Limitation 2. Potential for bias due to limited Inuit and First Nations representation. Beyond the decision to reserve community level engagement to a second phase of study, the current evaluation had relatively limited representation of First Nations and Inuit representatives, particularly at the regional and sub-program level (e.g., treatment centres, IRS RHSP, Mental Wellness Teams, etc.), due to a combination of reasons (i.e., condensed timeframe, limited capacity, and staff changeover since 2020-21). Therefore, findings that emerged from this study (phase one) cannot be generalized to represent all contexts or voices in the mental wellness space.

Mitigation 2. Efforts to mitigate this challenge included frequent follow-up, attending events/meetings to raise awareness about the evaluation, offering flexible formats for participation (e.g., condensed interview/phone call, responses in writing), and extending the evaluation timeframe to allow for additional contributors.

Limitation 3. The large scope of the evaluation limited a comprehensive assessment of all questions, sub-questions, and indicators. This study (phase one) was guided by 14 overall questions designed by the ISC Evaluation Branch, several of which had corresponding sub-questions and detailed indicators. While efforts were made to capture all priority issues in all discussions, the semi-structured nature of the interviews, coupled with limited availability of some key informants, and gaps in some program documentation constrained the assessment of all topics, questions, and sub-questions.

Mitigation 3. To mitigate this challenge, the interview guides were revisited to ensure priority questions and topics were covered in the interviews. Furthermore, interview conversations with some representatives (FNIHB staff) were scheduled for 90 minutes to maximize input. Given the mixed-method approach and phased design of the evaluation, it is also expected that gaps in knowledge could be explored and captured through other lines of evidence such as through a follow-up study (a phase two).

Finding 1: There is a great need for funding and support through the MWP to address the ongoing and intergenerational impacts of colonization and systemic racism and to support healing and well-being across the lifespan.

All lines of evidence highlight that funding through the MWP was crucial to supporting First Nations and Inuit to deliver mental wellness programs that respond to their unique priorities. While there were important differences in the realities, needs, and perspectives within and across First Nations and Inuit related to mental wellness, common threads were identified with respect to growing demands placed on services (discussed below and to be further explored in Phase Two).

Finding 2: Funding through the MWP is mostly relevant to the priorities of First Nations and Inuit because of its flexibility and recent funding enhancements in key areas. However, some considerations related to funding stipulations (e.g., capital spending) and need for services for priority populations were noted.

Opportunities for Further Alignment

A few challenges and corresponding suggestions were identified to further align the MWP with the priorities of First Nations and Inuit.

Need for capital/facility investments. While not unique to the MWP, several First Nations and Inuit key informants noted that the restrictions on use of community-based MW funding for capital expenses was an ongoing challenge as there were often considerable needs for community infrastructure to support programming (e.g., confidential spaces for counselling services, cabins and cultural sites, youth-based centers). For example, a few Inuit representatives described how an organization may have identified a programming need and received corresponding funding, though was ultimately unable to deliver the program as there were no available facilities and funding stipulations restricted capital purchases. In some cases, this can lead to carry forward despite evidence of program need. First Nations representatives highlighted similar difficulties with limited spaces for program delivery.^{Footnote 59}

"The funding has to come with some idea of infrastructure for mental health and addictions, this part has been missing. People often think, 'well, you can just do this work anywhere.' Well, you can't. You need a safe, confidential space. We don't think about this in mental health, but it actually impacts a lot of the work that we do."

"It's one thing to have a program, but it's another thing to have the place and space or the people to be able to deliver on that program's objectives. We need investments in infrastructure and not just programming funds. Things such as wellness camps to facilitate being on the land and connecting to culture for healing, this is really important to Inuit."

Federal/central agency funding stipulations. Some FNIHB representatives explained that funding stipulations introduced by central agencies have undermined the program's commitment to flexibility and self-determination. While the MWP amalgamated many of its funding streams through the Mental Wellness Alignment, key informants felt that rigidity and administrative requirements were being re-introduced to funding recipients as some funding received for the program continued to be administered as ‘add-on' funding for recipients to deliver within specified parameters, rather than as broad community-driven mental wellness funding.

"What tends to happen sometimes is, in announcing a new priority or seeking money to a particular area of concern, you get budget approval, but it comes with a level of scrutiny at the Minister's level or central agency level"

Population considerations. Some population-specific considerations were highlighted. While the program terms and conditions did not restrict population-specific services, several key informants in Inuit and First Nations contexts suggested that there was an overall gap in mental wellness programs and services for some priority populations, including children, youth, and family-based supports. This was often associated with an overall insufficiency in funding (i.e., children, youth and families services and supports can be funded under existing funding streams; most/all of funding is used for crisis or the highest need, leaving only a small portion available for prevention) alongside a lack of suitable facilities to deliver programs. Furthermore, a few indicated that programs may not have the capacity to meet the specific needs of 2SLGBTQQIA+ populations as staff may not have access to appropriate training while program spaces may not be perceived as safe and affirming.

Finding 3: Service access and uptake has grown. Regionally, First Nations and Inuit-led programs are showcasing promising approaches that are grounded in culture, strengths-based, trauma-informed, and responsive to priorities.

Access and Uptake

Reporting data from the IRS RHSP shows that the program saw a continued increase in demand over time as the number of hours of mental health counselling sessions grew by 57% between 2015-16 and 2020-21, and the number of clients per health and cultural support worker nearly doubled.^{Footnote 60} As indicated in section 4.1 above, numerous factors could explain this, including general growing need for services, the emotional impacts of settlement agreements, expansion of program eligibility access to mental health counselling services through the trauma-informed programs with the addition of the Missing and Murdered Indigenous Women and Girls Health and Cultural Support Program (2018) and Federal Indian Day Schools Health and Cultural Support Program (2020), increased dialogue and awareness of the experiences of IRS Survivors.

Text alternative for Number of hours of counselling sessions through IRS RHSP, 2015-2021

Fiscal Year	Counselling Sessions
2015-2016	41,823
2016-2017	51,622
2017-2018	62,053
2018-2019	58,589
2019-2020	70,803
2020-2021	65,812

Additional metrics that demonstrate growth in service access and uptake include:

• Treatment Centres: The table below shows an increase in admittance numbers for most services (in-patient, day patient, outreach/aftercare) based on available reporting data. Not displayed below, a review of the data also found that the proportion of treatment centres accepting clients on Suboxone increased considerably from 42% accepting Suboxone clients in 2015, to 71% in 2018, and the total number of clients admitted to centres grew from 3,646 in 2015-16 to 4,960 in 2017-18 (36% increase among treatment centres that completed reporting).^{Footnote 62}

Table 4. Type of treatment centre services accessed by clients, 2015-2018^{Footnote 63}

Treatment Centre AdmittanceTable note 1	Reporting Year
	2015-2016 (n=43)	2016-2017 (n=44)	2017-2018 (n=34)
Number of patients Accessing Inpatient Care	3,646	4,448	4,171
Number of patients Accessing Outpatient Care	3,382	2,791	2,686
Number of patients Accessing Day Patient Care	651	1,307	1,315
# Accessing Outreach-Aftercare	1,535	3,709	3,048
Table note 1 Annual reporting data indicates that reporting practices and interpretation varied in some cases across treatment centres, resulting in some incomplete data. Return to table note 1 referrer

• Mental Wellness Teams: Reach of the MWTs increased with the 2016 announcement of funding for four crisis response teams in Ontario, Manitoba, and Nunavut, and an additional 32 MWTs. As of September 2021, there were an estimated 63 MWTs serving 344 First Nations and Inuit communities.    
• According to departmental results data, in 2019-2020, 50% of First Nations and Inuit communities had access to MWTs – an increase from 15% in 2015-16.^{Footnote 64Footnote 65}

• Opioid Agonist Therapy Wrap-Around Services: Investments in 2017 supported increased access to OAT wraparound services (e.g., assessment, referral, treatment, counselling, cultural supports) at community-based opioid agonist treatment sites. While barriers to accessing treatment still existed by the end of evaluated period, the number of ISC-funded sites that offer OAT wraparound services increased from 15 (2017-18) to 72 (2020-21).^{Footnote 66}

Text alternative for ISC-funded sites offering OAT wraparound services increased

Fiscal Year	Counselling Sessions
2017-18	15
2018-19	58
2019-20	68
2020-21	72

A few key informants highlighted that while program reach and uptake can offer insights on changes within the MWP over time, these data do not convey the whole picture as it relates to the community and individual-level impacts of services offered (an area for investigation in Phase Two).

Finding 4: Findings from governance-level partners suggest that there were persistent challenges in access to medical detox services, case management and service transition, and access to treatment services and community-based substance use supports.

As described by several key informants and in program frameworks, a comprehensive mental wellness system requires commitment across partners of various levels – communities, First Nations and Inuit regional entities, provincial and territorial governments, and the federal government. While the Mental Wellness Program provides funding for some mental wellness services along the continuum, others fall within provincial and territorial health services (e.g., medical detox). Furthermore, the ability to deliver and access a full spectrum of care can vary regionally and across communities due to factors including human resource capacity, funding (i.e., funding amount, growth, duration), community size and available infrastructure^{Footnote 73} partnerships, cultural safety (e.g., of programs/services available in nearby centers), and remoteness.

Findings suggest that while funding through the MWP contributed to supporting access to a continuum of care, there were ongoing challenges across regions in access to a comprehensive system of supports. This appeared to be due to factors including limited jurisdictional coordination, difficulty accessing provincial/territorial services (e.g., medical detox, OAT prescribing), high demands on staff, and limited funding to deliver a comprehensive program/service plan. The key themes that emerged align closely with findings from the previous evaluation; however, validation from community-based perspectives is warranted.

Finding 5: Partnerships are important for supporting the MWP to respond to priorities and for advancing a coordinated system of care. Yet, a lack of provincial partnership and investment is an enduring challenge that has impeded progress and led to duplication.

Finding 6: The MWP undertook efforts to enhance flexibility and reduce funding siloes through the introduction of the Mental Wellness Alignment. Preliminarily, the Alignment supported more flexibility across funding streams, though building awareness of its intent and purpose should continue.

Finding 7: Regional First Nations and Inuit regional respondents generally perceived FNIHB-MWP staff as supportive and flexible. Some opportunities to improve were identified (i.e., internal management, communication, and engagement).

Finding 8: There was strong agreement that available financial resources within the MWP do not meet the demands for services, which greatly affect the ability of Inuit and First Nations to meet needs, develop stable operations, and retain a healthy workforce.

Community and Workforce Capacity

In addition to addressing resourcing, all lines of evidence highlighted that fostering a healthy and qualified mental wellness workforce is foundational to achieving meaningful outcomes in mental wellness services. An overall theme from the interviews and document review suggests that, while there was notable diversity in workforce needs across and within First Nations and Inuit contexts, there were common considerations broadly affecting community and workforce capacity. These factors are illustrated below. 

Text alternative for Illustrations of factors which can affect the mental wellness workforce

The factors which can affect the mental wellness workforce include:

• Competitive Wages
• Workforce wellness & supports
• Human resourcing
• Training and sharing knowledge
• Community context

Spotlight of Workforce Needs

According to key informants and the document review, First Nations and Inuit programs can face challenges in recruiting and retaining a qualified, culturally competent, and healthy mental wellness workforce due to many interrelated factors.

• Human resource shortages. Workforce shortages, including Indigenous substance use workers, were highlighted by some key informants as an ongoing challenge affecting the MWP due to factors including lack of competitive wages, recruitment and retention practices of provincial, territorial, and federal governments (e.g., recruitment to the Non-Insured Health Benefits Program), vicarious trauma and burnout, and an ageing workforce. For example, many cultural and emotional support workers within the Trauma-Informed Health and Cultural Support programs are Elders and survivors of the IRS, IDS, and Sixties Scoop and are transitioning out of the workforce. Accordingly, key informants expressed a great need for mentoring and support for the next generation of support workers.  
• Competitive Wages. While a comparative analysis of wages against provincial and territorial data was not within the evaluation scope, findings from some key informants and research reports suggest that there were continued challenges associated with competitive compensation. One study published by the Thunderbird Partnership Foundation showed that First Nations substance use workers earned approximately 45% less than their provincial counterparts despite high rates of accreditation and certification, which is attributed to outdated funding formulas.^{Footnote 82} Similar data was not available in Inuit service contexts. Some improvements may be evident with the availability of additional funding through Budget 2018, though key informants perceived competitive wages to be a continued systemic challenge due to the nature of time-limited enhancements.
• Training, sharing knowledge, and restoring capacity. The need for support to access training, knowledge sharing, and capacity building opportunities were identified based on a needs assessment conducted by the First Peoples Wellness Circle,^{Footnote 83} an environmental scan across the Inuit regions,^{Footnote 84} and interview discussions. This included access to peer support networks and training focused on topics such as complex trauma, Indigenous-guided critical incidence and stress management, and land-based healing.
• Community context: Some key informants explained that workforce needs can be magnified in remote, isolated, and northern communities due to high turnover rates, shortages of local, culturally competent staff, lack of housing in community and dedicated spaces for programs, lack of community resources to support additional infrastructure, and greater compensation required.

Key informants shared several suggested opportunities for both the MWP and the broader department to address workforce needs in partnership with communities:

• Leveraging and building awareness of resources developed by partner organizations (e.g., workforce wellness strategies, training modules)
• Development of a health human resource strategy, which could include laddered training and engagement of younger populations
• Enhancing the Aboriginal Health Human Resource Initiative allocations
• Supporting training opportunities that are close-to-home (e.g., in-territory training) and grounded in First Nations and Inuit worldviews

Finding 9: Efforts by the MWP to reduce siloes and support efficiency were observed through the transfer of FNIHB to ISC. The opportunities introduced through an integrated department could be further maximized.

With the creation of ISC in 2017, FNIHB was formally transferred from Health Canada to the new department, bringing together social, health, and infrastructure services, from both Health Canada and Indigenous Affairs and Northern Development Canada. The 2018-19 Departmental Plan stated that the primary mandate of ISC is to improve the quality of services delivered to First Nations, Inuit, and Métis peoples by working to close socio-economic gaps and ultimately ensure that Indigenous peoples have control over services and programs.^{Footnote 85}

Key informants generally did not perceive any direct, program-level impacts to the MWP following the department's creation. More broadly, several considerations (strengths and opportunities) were identified following the integration of FNIHB within ISC.

Intra-departmental collaboration and partnership. Approximately half of FNIHB staff felt that aligning various Indigenous-specific programs and services under a common mandate was advantageous as it encourages a more coordinated and collaborative approach to supporting First Nations and Inuit. For instance, this led to opportunities for shared learning and fostered joint discussions to address key overlapping issues (e.g., child welfare, community safety).

At the same time, several FNIHB staff and First Nations representatives felt that intra-departmental collaboration could be further leveraged as programs and service areas continued to operate in siloes despite the multi-faceted nature of many priority issues affecting mental wellness (e.g., the social determinants of health). This was attributed to factors including:

• A lack of internal capacity,
• A lack of departmental direction, and
• A program-by-program approach to funding and supporting communities

"Some of the pros are being able to work more collaboratively with regional operations when communities go into crisis. What was challenging prior to ISC was, [FNIHB] would do our own calls with the community, and then [Indigenous Affairs and Northern Development Canada] regional operations would have their own calls if necessary. But they weren't jointly together. Now, when a community declares a state of emergency, it is FNIHB, Regional Operations, and our provincial colleagues. So, together, we're able to kind of cover off more ground, and be more flexible and creative."

Relationships and engagement. Key informants suggested that while the creation of ISC supported a more collective focus, there were differences across the department with respect to partner engagement processes and relationship building, citing some areas as reputed to be historically inflexible, risk averse, and less relational. Some First Nations partners agreed with this sentiment and suggested that the creation of a new department by amalgamating parts of two independent departments added, rather than removed, bureaucratic layers. However, it is important to note that some Inuit representatives held the opposite view, that the department's creation had led to improved relationships and more flexibility (e.g., in how FNIHB/ISC staff work with partners) as compared to other federal departments (including Health Canada).

Departmental efficiency. Some felt that there were inefficiencies associated with more complex budget submissions and corporate reporting, additional policy layers (e.g., FNIHB Strategic Policy and ISC Strategic Policy), and duplication in governance structures (e.g., committees, working groups) which had not yet been resolved. As well, a few perceived the MWP to have more difficulty in effectively advocating for funding against other priority areas (e.g., housing, education), given that the impacts of public health programming were difficult to capture in the short-term.

Finding 10: Demonstrating performance within the program is challenged by reporting processes (i.e., streamlined reporting), available indicators and outcomes, and short timeframes of investments. Performance measurement approaches could be improved by applying First Nations and Inuit concepts of wellness and supporting capacity to collect meaningful data to inform planning on the basis of these concepts.

The 2016 Mental Wellness Program Evaluation outlined several recommendations related to performance measurement within the program, including:

• Developing a comprehensive Performance Measurement Strategy to guide the collection and use of performance data
• Supporting community capacity through sharing best/promising practices
• Continuing to conduct special research studies focused on specific areas within the program

Following the evaluation, a program Performance Measurement Strategy was developed with a revised logic model, program outcomes, and performance indicators. The Strategy also included detailed information regarding the department/organization responsible for collecting the information, the frequency of data collection, and how the data was collected. Further to this, the MWP supported the development of the partner-led "Wise Practices for Life Promotion," an on-line resource focused on elevating the good work underway in First Nations communities across Canada and built on work funded by the MWP that was published in 2009. Several special studies were also conducted by partner organizations throughout the evaluation timeframe, including research assessments focused on the National Aboriginal Youth Suicide Prevention Strategy, Mental Wellness Teams, Indian Residential School Resolution Health Support Program, and treatment centres as well as an ITK commissioned evaluation of the National Inuit Suicide Prevention Strategy, which provided nuanced findings with respect to needs, impacts, and opportunities for the MWP.

While the MWP undertook efforts to improve performance measurement, some challenges were identified through the document review and primary data collection:

Complexity of demonstrating impact: Some noted that there are several factors that can make it difficult for the MWP to demonstrate the impact of funding investments through the existing reporting mechanism and tools. This included the complexity of individual and community mental wellness and public health emergencies (e.g., opioid crisis) against short investment timeframes (e.g., 2 years), the role of many partners, jurisdictions, and sectors in delivering mental wellness services, and the program's continued focus on reduced reporting and flexible funding.

Outcome measurement and data availability: According to the Program's 2020 Performance Information Profile (PIP), the risk of not having sufficient information for decision-making was noted as "very high".^{Footnote 86} In-line with this, a review across the Performance Information Profiles (PIPs) available as part of the evaluation (2017-2018, 2018-2019, and 2020-2021) found that there were considerable changes to both expected program outcomes (long, medium, short term) across the documents and to the relevant indicators, which the program implemented in an effort to align with changing policies, increased flexibility and reduced reporting requirements. Some indicators were decommissioned and no longer collected (n=6) and others were newly introduced (n=3), and some performance indicators did not have established targets (n=3). As the MWP logic model was also updated during the evaluation period (with a focus on more broad short term, medium term, and long-term outcomes), some of the performance indicators in the most recent PIP did not align with the revised expected outcomes (e.g., "increase in healthy behaviours" was removed from 2020 logic model).

Measures of interest: Alongside measurement and attribution challenges, FNIHB Staff noted that the MWP received additional requests from central agencies and other areas of government to report on investment impact (e.g., "on-the-ground data" in addition to annual reporting data), despite the department's focus on reduced reporting; further to this, the indicators of interest were often western, deficit-based measures that are used by a range of organizations (e.g., suicide rates), which may not align with Inuit and First Nations worldviews on wellness (e.g., strengths-based, holistic).

Community/organizational capacity: Some First Nations and Inuit representatives also expressed a need to focus on increasing the capacity and resources available to community-based staff to ensure there are adequate data systems, processes, and strategies in place to collect meaningful data. While not widely validated by communities, it was also suggested by a few that the required reporting data might not be relevant to support long-term planning within communities. The list below presents opportunities to improve performance measurement as identified by key informants during primary data collection (FNIHB staff, First Nations, and Inuit representatives). Some of these opportunities could potentially be implemented within the program in the short to medium term (e.g., 1, 3, 4, 5), whereas others may require a more systems-level approach that goes beyond the MWP (e.g., 2, 6).

1. Increasingly emphasizing qualitative approaches (e.g., program and community stories) and providing partners with more formats for reporting outcomes to demonstrate impacts of investments
2. Continuing to build awareness and understanding within government of the department's commitment to flexible and streamlined funding and reporting approaches
3. Collaborating with partners (nationally and regionally) to ensure reporting and performance measures are relevant (e.g., hosting strategic planning sessions with regional agreement holders to co-define reporting measures of interest)
4. Continuing to support assessments and special projects conducted by national partner organizations to gather comprehensive sub-program and thematic findings.
5. Leveraging existing frameworks that advance First Nations and Inuit strengths-based perspectives on mental wellness outcomes and mapping the MWP's performance measurement approach against these outcomes (e.g., First Nations Health Managers Association wellness indicators, Inuit indicators of wellness)
6. Focusing on supporting community capacity for monitoring and evaluation activities that can help to inform long-term planning and control over services (e.g., measurement planning workshops, developing and sharing resources, learning from existing data)

Finding 11: Both Inuit and First Nations representatives described youth-based mental wellness programming and services as an area requiring increased attention within the MWP and across the department.

Youth and family-based programs were described by approximately half of all key informants as an area of priority. While many First Nations and Inuit youth experience good health, some pointed to a great need to support youth impacted by intergenerational trauma and in the wake of many destabilizing events including the continued systemic and interpersonal racism, grief and loss, suicide clusters, environmental emergencies, findings from truth gathering processes, opioids and other substance use crises, and the COVID-19 pandemic. As well, a few key informants within remote, isolated, and northern contexts highlighted that youth can face unique challenges due to an overall lack of services available (e.g., mental health therapists), feelings of isolation (e.g., when travel out of community is difficult), limited programming (e.g., recreational activities), and stressors associated with the social determinants of health (e.g., food insecurity, inadequate housing).

Notwithstanding the importance of flexibility for regions and communities to identify and deliver programs in-line with their unique priorities, several key themes emerged with respect to perceived overall gaps in service offerings:

• Strengths and resiliency-based youth programming (e.g., focused on cultural identity, peer relationships, land-based and traditional)
• School-based initiatives (e.g., in-school counselling services)
• Family-based programs; and
• Youth and family-based treatment centre services

Against this, various challenges were highlighted with respect to the capacity of communities/organizations to support youth and family-based services. As previously mentioned, Inuit representatives highlighted challenges associated with a shortage of program spaces and understaffing, which led to unspent funding in some instances. First Nations representatives highlighted similar difficulties (program/recreation spaces, capacity), and also noted that when communities encounter persistent crises, already-limited funding for prevention activities can be eroded.   

Some felt there have been limited targeted funding enhancements within the program to address these needs (while acknowledging that funding does not currently restrict programming for these populations.^{Footnote 87} As well, while there are adjacent programs that fund activities for youth and families (e.g., FNIHB Healthy Child Development program, Jordan's Principle, Child and Family Services), there is often not a mental wellness component to them and there are challenges to working across programs due to different target populations as well as terms and conditions. This suggests that there may be an opportunity to improve intersections between programs through more collaborative work. A few FNIHB representatives also perceived an overall lack of coordination across ISC for youth programming, leading to concerns that youth are "falling through the cracks." An exception to this coordination challenge was identified within the FNIHB Ontario region through the clustering of other funding envelopes (see: regional spotlight).

Finding 12: Climate change is disrupting important and distinct pathways for good health and well-being among First Nations and Inuit (e.g. access to traditional activities, emergency events) in complex ways that will further challenge the MWP operating environment and increase need.

Climate change is disrupting many of the determinants of well-being for Indigenous peoples, and which cannot be addressed through the MWP alone, particularly as there are programs, such as FNIHB's Environmental Public Health Program, and departments, such as Health Canada and Environment and Climate Change Canada, leading this file. A 2022 report by the National Collaborating Centre for Indigenous Health summarizes some of these pathways:^{Footnote 88}

• Limited ability to hunt, fish, trap, forage, and spend time on the land, which is a critical pathway to mental health and well-being
• Disruption of the transmission of intergenerational knowledge and land skills to younger generations, which is a critical component of cultural identity
• Dislocation and damage to lands through extreme climate events, such as wildfires, can create perpetual experiences of stress and ecological grief

"That impacts mental wellness for Inuit more than people realize, because when you're not used to the changes in the migration of animals or sea ice conditions, you might not be able to have a successful hunt. This not only impacts the hunter's family, but also who they would normally share their food within the community, creating food insecurity, which also impacts mental wellness."

The unique effects of climate change for communities in the North are increasingly documented and reported. For Inuit in Inuit Nunangat, the literature suggests that climate change is disrupting many activities that are beneficial for mental wellness, including spending time harvesting, fishing, and preparing country foods, traveling to cabins, and accessing culturally significant sites.^{Footnote 89Footnote 90} A few key informants also reported that climate change has exacerbated concerns for food security, which is already high in many regions. The concept of ‘solastalgia' has been discussed within the literature as it relates to climate grief experienced by many Inuit – defined as "a feeling of home sickness without ever leaving home" because of the visible changes to the landscape.^{Footnote 91}

Similarly, a 2018 article published by Dodd et al. suggests that remote and isolated First Nations can be especially impacted as opportunities for activities on the land are threatened (e.g., fishing, hunting, harvesting, medicine picking), ice road seasons are shortened, the costs of supplies are inflated, and the threat of displacement is increasing with more extreme wildfire and flooding.^{Footnote 92}

Despite the significant potential implications of climate change for the MWP, it was not always a direct area of focus among regional FNIHB staff. Some FNIHB-MWP representatives indicated that they supported First Nations and Inuit in the following ways:

• Offering surge support in collaboration with Health Emergency Management
• Collaborating with treatment centres to develop service plans if evacuations are required
• Coordinating services, such as pop-up, wrap-around treatment options for community members

As well, MWTs and Health and Cultural Support Workers were highlighted by a few representatives as critical to providing supports to displaced community members.

With that being said, a few regional staff noted that climate change was not a significant area of focus within their role and perceived the program to be sufficiently flexible to enable communities to pivot funding when required. Given increasing attention, several representatives agreed that coordination and collaboration with Health Emergency Management should increase and that there were opportunities to work alongside communities in emergency planning.

"We need to be more proactive to support Nations that we know for a fact will go through a wildfire response, it's yearly for some, so not waiting for the event to happen. So, in terms of resourcing: working on planning with partners, building some type of protocol beforehand on how these sorts of events can be managed and mitigated before it happens. We have a very responsive attitude, but now that we have had a very unprecedented season, we can learn from that and have conversations with Nations to support in preparation for what might happen."

Finding 13: The MWP has taken steps to support self-determination and advance Indigenous control over services; notwithstanding the wide diversity of contexts, some overall barriers and opportunities were identified (i.e., funding, intra-governmental alignment, restoring capacity, partnership building).

Program documents highlight that advancing the vision of self-determination and the return of control over services is a key theme in FNIHB's partnerships with Indigenous leaders, organizations, and communities. Key informants stated that the MWP had aligned with this vision in the following ways:

• The MWP offered a high degree of autonomy and flexibility to communities/organizations to plan and deliver services according to their priorities, and which was further enhanced by the Mental Wellness Alignment;
• Reporting was streamlined, which can ease administrative requirements on communities (however, as described elsewhere, some challenges with reporting were also identified, including changing templates, burdensome requests from central agencies and, additional reporting requirements that may be added to new funding investments.)
• While not akin to service transfer, the program was "de-centralized" through locally tailored regional partnership structures, which prioritize First Nations and Inuit-led decision making regarding how funding is allocated and key priorities
• Treatment centres were governed through independent boards and not by ISC, allowing centres to develop unique models and programming
• Training and workforce development activities were largely managed by Indigenous partners to encourage Indigenous-led training, restoring capacity, and workforce standards; additionally, research and evaluation activities were increasingly undertaken by partners (e.g., conducting needs assessments, special studies)

At the same time, it was noted that the journey to advancing service transfer was complex, unique to each community, Nation, and/or region, and that there were key barriers that can slow the implementation of this vision. A lack of adequate, sustained funding was reported as the number one factor impeding the advancement of service transfer as lack of sufficient funding limited the extent to which communities could effectively deliver a continuum of services, retain qualified staff, develop stable operations, access training and restore capacity, and engage in long-term planning. Further to this, when funding arrangements are complex, fragmented, and uncertain, communities were less able to develop holistic health programs. Several other factors were identified:

Funding stipulations and reporting accountabilities to central agencies^{Footnote 93} were described by some as inconsistent with ISC's priority for service transfer as these stipulations and accountabilities continued to advance federal government priorities and not those of First Nations and Inuit. Communities/organizations were required to deliver reporting on outcomes that may not be meaningful to them or effective to their decision making.

Internal collaboration and integration between program areas and within the department could be improved to ensure a coordinated and consistent effort in moving toward service transfer. Some felt that ISC was not achieving its goal of transfer due to high risk aversion, differing approaches and perspectives across the department, and a lack of clarity, direction, and communication.

A review from the National Collaborating Centre for Indigenous Health^{Footnote 94} and key informant discussions affirm that while there is not a singular "best practice" approach to advancing service transfer, there are common features and promising practices (see Figure below).

Text alternative for Illustrations of factors which can advance service transfer based on key informant discussions and the literature

The factors which can advance service transfer based on key informant discussions and the literature include:

1. Funding

• Funding models that are adequate, sustainable, flexible, consolidated, and long-term (and which include governance, administration, and true service costs), with simplified criteria.

2. Building Capacity

• "Scalable" self-determination based on capacity.
• Resourcing and supporting workforce development, health planning, data systems and management.
• Ongoing technical and administrative support to move to increasingly flexible arrangements.

3. Partnerships

• Partner engagement in planning and policy processes.
• Intra-departmental collaboration and alignment to reduce siloes and ensure a common approach.
• Clearly articulated roles and responsibilities between federal, provincial/territorial, and Indigenous governments.

Finding 14: The COVID-19 pandemic simultaneously created increased need for, and challenges, to deliver the MWP; but new and flexible resources and innovative practices helped mitigate the impact and provided lessons learned for the future.